North Dakota Department of Health School Immunization Survey

2013-2014 North Dakota School Immunization Requirements (pdf)
School Immunization Survey Instructions (pdf)
2013-2014 School Memo
School Immunization Guide (pdf)

Return to Immunization Homepage

School Information

Name of the SchoolPublic or Private School
Grade at School EntryGrade at Middle School Entry
Institution AuthorityInstitution Authority Phone Number
Person Submitting ReportPerson Submitting Phone Number
Revised ReportEmail Address

General Questions

Does your school currently have access to the North Dakota Immunization Information System(NDIIS)?
If yes, does your school pull immunization records from NDIIS for student records?
Who determines which students are up-to-date with their immunzations? If other please specify
Does your school exclude students who are not up-to-date with their immunizations or do not have a signed exemption within 30 days of the beginning of the school year? If other please specify

Student Enrollment Information

GradeKindGR. 1GR. 2GR. 3GR. 4GR. 5GR. 6GR. 7GR. 8GR. 9GR. 10GR. 11GR. 12
Enrolled:

Exemption and Missing Record Information

GradeKindGR. 1GR. 2GR. 3GR. 4GR. 5GR. 6GR. 7GR. 8GR. 9GR. 10GR. 11GR. 12
Students with no immunization record:
Students claiming medical exemption:
Students claiming religious exemption:
Students claiming philosophical exemption:
Students claiming moral exemption:
Students claiming history of disease exemption:

Vaccination Status of Students

GradeKindGR. 1GR. 2GR. 3GR. 4GR. 5GR. 6GR. 7GR. 8GR. 9GR. 10GR. 11GR. 12
Fully immunized with Polio vaccine (IPV or OPV):
Fully immunized with DTP/DTaP/DT vaccine:
Fully immunized with MMR vaccine:
Fully immunized with Hepatitis B vaccine:
Fully immunized with Varicella (Chickenpox) vaccine: (2 doses required)
Fully immunized with TD/Tdap:      
Fully immunized with Meningococcal vaccine: